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Conclusions: This study suggests that the cardiovascular risk factor profile for Turks in Turkey is different from that of Caucasian men resident in the UK. Further research is needed to ascertain the significance of these findings.
Are There Differences in Lipid Profiles Among Chinese Males Residing in the UK, Chinese Males Residing in Hong Kong and Caucasians in the UK?AV Kasbekar, V Andrews1, M Gangola2, C.W.K.Lam3, R Swaminathan1
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Results are given as mean +/- SD except for Lipoprotein (a) where it is given as median and range.
Conclusions: The profile of risk factors differs in these groups and more studies are needed to evaluate their relevance for cardiovascular disease among ethnic Chinese who reside in the UK.
Insulin resistance has been implicated in the increased risk of cardiovascular disease and non-insulin dependent diabetes mellitus (NIDDM) in South Asians (Stern MP et al., Diabetes 1995; 44: 369-74). Studies in the UK have suggested that South Asians are insulin resistant (Whincup PH et al., BMJ 2002; 324: 635). It has been suggested that the insulin resistance may be present in South Asians living in India, which would imply that it might be an inherited trait (Williams B. Lancet 1995; 345:401-2).
Methods: In order to further investigate this theory, we performed a prospective study measuring fasting insulin and glucose concentrations. Young male subjects of European origin were compared with second generation South Asians in the UK and Indians living in India. Insulin resistance was calculated using the HOMA method model.
Results: The body mass index (BMI) of Indians residing in India was significantly lower (19.8 +/- 4.48) than that of Europeans (23.9 +/- 3.23) and South Asians in the UK (23.2 +/- 3.67). Insulin resistance was also significantly lower among Indians in India (1.42 +/- 0.81) compared to Europeans (3.04 +/- 2.99) and South Asians in the UK (2.38 +/- 1.13) (p<0.001 by ANOVA). There was a significant correlation between body mass index and insulin resistance (r=0.382, p<0.001). Insulin resistance among Indians residing in India remained significantly lower than the other groups, even after correcting for the body mass index.
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Results
given as mean +/- standard deviation
Conclusions: Insulin resistance may not
be present in all groups of South Asians.
Homocysteine is an independent risk factor for coronary heart disease (Chambers JC et al., Lancet 2000; 355: 523-7). Indian Asians are reported to have a reduced intake of folate, a nutritional determinant of homocysteine (Abraham R et al., Hum Nutr Appl Nutr 1987; 41:164-73). Recent reports have suggested that some groups of South Asians have higher serum homocysteine and lower folate than Caucasians. Another predisposing factor to higher serum homocysteine is the thermolabile variant (677CÆT) of the MTHFR gene (Michie CA et al., Lancet 1998; 351: 1105).
Methods: We examined fasting levels of homocysteine, folate and MTHFR genotype in a group of 114 healthy, non-diabetic Sri Lankans (60 males and 54 females) living in London.
Results:
Sex differences were found for serum homocysteine as previously reported. Four subjects (4%) had serum homocysteine concentrations of >14µmol/l, the upper limit of normal in folate replete people. Their serum folate was significantly lower (5.5 +/- 0.91 vs 8.9 +/- 0.34, P=0.038).
The allele frequency of the thermolabile variant MTHFR gene (10%) was lower than the 34% frequency reported in various European populations.
Folate intake in the Sri Lankan population was adequate to maintain a normal serum homocysteine concentration.
The table summarises serum homocysteine, serum folate and red cell folate (+/- standard error of means) according to MTHFR status.
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Conclusions: Abnormal homocysteine metabolism due either to the TT genotype or to inadequate folate intake is unlikely to be involved in the increased incidence of coronary heart disease in this population. Serum homocysteine concentration needs to be interpreted with genotype data for a specific ethnic group.
There is interest in serum total sialic acid as a cardiovascular risk factor (Lindberg G et al. BMJ 1991; 302: 143-46).
Methods: The relationship between conventional cardiovascular risk factors and serum sialic acid was explored in a group of 100 healthy young subjects (54 females and 46 males; age 20.7 +/- 0.89 years) by measuring serum total sialic acid, fasting plasma insulin, fasting glucose concentration, serum cholesterol and triglyceride concentrations.
Results: In multiple regression analysis, serum total sialic acid correlated independently with serum cholesterol (0.113 p < 0.001) and fasting plasma insulin concentration (0.036 p < 0.04). In females, serum total sialic acid correlated independently with systolic blood pressure (0.181 p < 0.001), diastolic blood pressure (0.053 p < 0.04), serum cholesterol concentration (0.125 p < 0.002) and fasting plasma glucose concentration (0.056 p < 0.03). There was no significant independent correlation between serum total sialic acid and any of the other variables in males.
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Conclusions: This is the first demonstration of a significant univariate correlation between serum total sialic acid and fasting insulin in normal healthy subjects. The association between insulin resistance and cardiovascular disease (Stout RW. Lancet 1987; 1: 1077-1079), may explain the association between serum total sialic acid and cardiovascular disease.
Serum total sialic acid has been reported as a cardiovascular risk factor (Lindberg G et al., Int J Epidemiol 1992; 21: 253-57), but whether there are racial differences is unknown.
Methods: Healthy young subjects (62 females and 62 males; ages 20.0 +/- 0.9 years), 68 of whom were of South Asian origin (37 females and 31 males) and 56, Caucasians (25 females and 31 males) were studied. Fasting blood samples were used for measurement of serum sialic acid.
Results: Serum total sialic acid was significantly higher in the South Asian males than in age-matched Caucasian males (74.3 +/- 12.3 mg/dL vs 68.2 +/- 13.0 mg/dL, p < 0.02). However, in females, serum total sialic acid was significantly higher in the Caucasians as compared to the South Asians (76.0 +/- 13.1 mg/dl versus 68.2+/- 13.0 mg/dL, p < 0.01).
Conclusion:
We conclude that serum total sialic acid levels
may differ among racial groups and also may be
useful to identify individuals at risk for cardiovascular
disease. Large prospective studies may help to
explain why serum total sialic acid is a reputed
cardiovascular risk factor and shows racial differences.
The incidence and outcome of stroke and are well defined in the developed world. However, in the developing world and particularly in the Gulf region, they are not well described.
Methods: The objective of this study was to investigate incidence and outcome of stroke in a geographically defined population admitted to Hamad Hospital with cardiovascular disorders between January 1991 and December 2001.
Results: Of the total of 20,856 patients treated during the ten year period, 8446 (40.5%) were Qataris. There were 53 Qatari patients and 46 Non-Qatari with stroke. Associated factors are summarized in the table below.
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There were no significant differences among groups in postmenopausal status, previous myocardial infarction or surgical revascularization (CABG).
Conclusions:
The current population-based study of Qatari nationals
residing in Qatar characterizes for the first
time the incidence of stroke in the Gulf region,
its associated conditions and the outcome among
cardiac patients.
Coronary angiography is undoubtedly the gold standard for diagnosis of coronary artery stenosis. If, however, a critical and proximal lesion in the left coronary system could be suspected from other investigations, earlier identification of such patients might salvage more myocardium and minimize morbidity and mortality. The large area of the ventricle at risk makes recognition of such ECG patterns critically important to prevent extensive anterior myocardial infarction and its complications.
Methods: Serial 12-lead electrocardiograms were recorded in the emergency room to identify certain T-wave changes in precordial leads on or shortly after admission in patients with typical angina fulfilling the criteria of Wellens. In atypical anginal pain, treadmill exercise ECG was done for evidence of more serious lesions in left main coronary artery. This was especially useful if it revealed ST-elevation during exercise with a normal resting ECG.
Results: According to those criteria one patient was diagnosed in the emergency room to have a tight lesion of the left anterior descending artery and sent directly for urgent revascularization. A second patient underwent urgent CABG for left main coronary artery disease.
Conclusions:
Resting ECG and/or treadmill ECG can provide important
information which complements coronary angiography
and may shorten the door-to-treat time.
The current study reports the first family with confirmed myofibrillar myopathy (MFM) in the Middle East and the third family worldwide.
Methods: A Qatari family consisting of one brother and three sisters was studied. This report focuses mainly on the clinical presentation and investigations done to diagnose “myofibrillar myopathy”, including echocardiogram, cardiac catheterization, cardiac and skeletal muscle biopsy, electromyography and electrophysiology studies. It also reviews the current literature.
Results: The brother had restrictive cardiomyopathy and life threatening arrhythmia requiring permanent pacemaker placement at the age of 16 years. Three years later, he developed skeletal myopathy. One sister underwent heart transplantation for severe hypertrophic cradiomyopathy at the age of 15 years. The other sister had permanent pacemaker implantation for complete heart block at the age of 21 years, and, at the time of the study, she had nearly normal echocardiographic findings. Both sisters have no clinical myopathy.
Conclusions:
This study highlights the importance of considering
this disease in young patients presenting with
idiopathic cardiomyopathy and/or AV block in the
Gulf States. It is also the first report of two
different types of cardiomyopathy and two different
indications for permanent pacemaker placement
in the same generation of a family with this disease.
Qatar is a fast developing country with a population in excess of 700,000 from a variety of different countries and cultures. Hamad General Hospital is a state-run hospital with the only Cardiology Department in the country.
The Cardiology in-patient areas have more than 60 beds and employ about 130 nurses.
Methods: The problem of standardization of nursing methods to provide ultimate and constant patient care was addressed by recognizing that nurses come from very different cultures and training centers. It was also acknowledged that culture plays a big part in the image of nursing and in the ability of the nurse to see herself / himself as a professional person and act accordingly. Nursing administration also underwent beneficial changes. Nurses were encouraged to follow their chosen career path and to become involved in patient satisfaction surveys, performance improvement issues and research.
Results: Great strides were made in the past few years to provide capable, up-to-date, well-informed and confident nurses in the Cardiology Units. This resulted in an ongoing process, which extended into the patient/family/ community teaching and rehabilitation areas as well.
Conclusions:
With the high incidence of coronary, artery disease
in Qatar, our cardiology nurses need to be able
to work confidently with their patient and also
be able to help in prevention of cardiac disease
and promotion of a healthy heart.
To study the influence of the minK gene polymorphism on the development of atrial fibrillation (AF) in the patients with sick sinus syndrome (SSS), two hundred eighteen patients with SSS were examined:
Methods: Patients were divided into three groups: Group I had 104 patients with the SSS but no paroxysmal AF (42 men, 62 women, mean age 68.17 ± 8.93 years). In Group II, 84 patients with the SSS had paroxysmal AF (21 men, 63 women, mean age 69.66 ± 7.77 years). Group III consisted of 30 patients with a long-term history of the SSS and chronic AF that developed less than 6 months before the enrollment into the study (14 men, 16 women, mean age 69.88 ± 7.81 years). The minK gene genotypes (GG, SS and GS) identification was carried out with use of polymerase chain reaction with subsequent restriction analysis. The Î2-test was used for the statistical analysis.
Results:
In the patients of groups I and II, the 38GS-genotype
of minK gene was found the most frequently (groups
I – 56.7%, II – 55.9%, III – 36.7%). There
was a significantly increased portion of the 38GG-genotype
patients in the group III as compared other groups
(groups I – 23.1%, II – 30.9%, III – 56.7%, p
I-II >0.05, p I-III 0.0002, p II-III 0.006). At
the same time, the 38SS-genotype was found in
only 2 of the group III patients (6.7%). The odds
ratio (OR) for chronic AF in the patients with
1 mink 38G allele was 2.87 (95% Cl 0.65 – 12.67)
compared with the patients with no mink 38G allele.
A higher OR of 3.61 (95% Cl 1.64 – 7.96) was obtained
for patients with 2 minK 38G alleles.
Conclusions: Correlation between the minK 38G
allele and the chronic AF in the patients with
SSS was found, and an increased risk of chronic
AF in the patients with 2 minK 38G alleles was
shown.
Idiopathic pericardial effusion is uncommon.
Methods: We present an 18-year-old male with idiopathic pericardial effusion and a review of the literature.
Results: An eighteen-year-old male was hospitalized in September 2001 with a large pericardial effusion. This was discovered during routine medical examination for entry into military college. One week earlier, he had experienced flu like symptoms. Initial investigations during admission for observation included those for malignancy and tuberculosis as well as connective disorders. These were all negative. The patient was treated with multiple medications, steroids, colchicine, and NSAIDs, but without improvement. Eventually, he underwent creation of a pericardial window, but without a good response. In the end, the patient had sub total pericardiectomy, following which he remained asymptomatic. Echocardiography one and two years after the procedure showed no reaccumulation of fluid, although both this and the electrocardiogram showed biatrial enlargement throughout his period of observation.
Conclusions:
Most cases of idiopathic pericardial effusion
are probably of viral etiology.
Hypertension is among the most prevalent cardiovascular problems in public health. Although easily detectable on screening, untreated, it can lead to cardiovascular morbidity and mortality.
Patients may be asymptomatic or mildly symptomatic, and once identified, should be treated regularly.
In Bahrain, the number of patients with hypertension and its complication is comparatively high.
Methods: Three studies were done in Salmaniya Medical Complex in 1987,1994 and 2002 to investigate the incidence and complications of hypertension. Systolic pressure of more than 140/90 was the entry criteria for the study.
Results: Ages ranged from 26-89 years. A significant number of patients (21.5%) had
hyperlipidemia. Comparative analysis showed increasing numbers of patients with hypertension over time, but a reduction of complications as summarized in the chart.
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Conclusions:
As a result of awareness and educational programs
by private and government health agencies and
prompt treatment, the incidence of complications
of hypertension has been reduced to 20% in Bahrain
as well as world-wide.
To evaluate if selection of monitoring sites would optimize anesthetic and surgical management of neonates with duct dependant circulation, we reviewed our experience with coarctation of the aorta and hypoplasia of the aortic arch.
Methods: 73 neonates (M: 32, F: 41) weighing between 900 and 3800 grams (mean = 2662) and aged 3 to 21 days (mean = 11.7) that were operated since September 1998 were analyzed retrospectively. Of these, 24 cases, 12 of whom had associated arch hypoplasia, were included in the study. All 24 patients received PGE1 infusions until PDA ligation. The right radial and a lower limb artery were cannulated in addition to standard monitoring techniques. Pre and post ductal pulse oxymetry probes were also placed. Until the time of PDA ligation, a Qp: Qs ratio around 1:1 was achieved by avoiding hyperoxia and hypercapnea, with uncorrected pH up to 7.25 and aiming for a preductal SaO2 of around 85%. Proximal aortic cross clamp (ACC) placement was guided by changes in waveforms in the right radial artery and the pre-ductal pulse oxymetry trace. Pulmonary artery (PA) banding was performed in 6 cases, guided by a reduction in SaO2, ETCO2, and PA pressures.
Results: Prior to PDA ligation, all patients were stabilized with PGE1 infusions and the maintenance of Qp: Qs ratios. The proximal ACC was adjusted on 12 occasions in the 12 patients with arch hypoplasia. Total ACC duration ranged from 13 to 35 minutes (mean=26). The repair was redone on 6 occasions at the time of initial operation, based on persisting pressure gradients between the right radial and the lower limb artery. One baby had a residual gradient post operatively.
Conclusions:
Prior to PDA ligation, pre and post ductal
SaO2 monitoring helped achieve hemodynamic stability
and maintain good systemic perfusion through the
PDA. The right radial artery pressure trace and
the right upper limb SaO2 trace facilitated placement
of the proximal ACC without compromise of carotid
blood supply in patients with arch hypoplasia.
The lower limb pressure trace contributed in the
assessment of the coarctation repair and served
as a portal for post ductal blood gas analysis.
We conclude that proper selection of monitoring
sites does improve the final out come of surgery
for these complex congenital heart lesions.
Material and Method: A total of 555 patients underwent total arterial revascularization with or without associated procedures between January 2000 and June 2003.
Mean age of the patients was 56.6 yrs, ranging from 27 to 81 years.
Of these 38% had Diabetes, and 100 had left main stem disease.
Recent MI was present in 20 patients. In 310 patients LVEF was less than 0.35.
The mean number of 3.2 distal anastomosis was performed using a combination of LIMA, RIMA, and Radial artery as a pedical or composite graft. 244 patients were done off-Pump.
Results: On the basis of electrocardiographic and enzyme changes, two had perioperative myocardial infarction. 23 patients had transient ST elevation. Seven patients had additional long saphenous vein graft. Incidence of re-exploration for bleeding was 1.9%. Neurological complications were nil and 3 had pulmonary complications. Sternal wound complications were present in two patients. In hospital mortality was 1.6%. All but two survivals were discharged from the hospital between 6-8 days. Those who underwent postoperative angiography showed string like LIMA in two and Radial in one.
Conclusion:
Usage of total arterial coronary revascularization
can be extended to a majority of subsets of coronary
artery disease by judiciously using combinations
of composite grafts. Beating heart total
arterial revascularisation although technically
demanding has its advantages.
Transcatheter Amplatzer device closure has been used to close muscular ventricular septal defects with satisfactory results. A new asymmetric Amplatzer perimembranous ventricular septal occluder has been specially designed for closure of perimembranous ventricular septal defects (VSD). We report our experience with VSD device closure from January 1, 2003 till December 1, 2003 using the new Amplatzer perimembranous and muscular ventricular septal occluders. During the 11 month period we closed 17 patients with VSD percutaneously, 13 perimembranous and 4 muscular VSDs. The mean age was 9 years (range 2.5 - 18 years), mean weight of 33 kg (range from 10.6 - 83 kg). The mean VSD size by transesophageal echocardiogram was 9.7 mm (range 6 -16 mm); Qp:Qs mean of 1.44:1 (range of 1.2:1 to 2.4:1). The mean device size was 10 mm (6 - 16 mm). Immediate and complete closure was achieved in 15 patients (~90%). One patient with perimembranous VSD had a small residual shunt around the device and one patient with apical VSD had a residual small shunt around the device. No major complication like death, CVA bleeding or perforation has occurred with our experience. Minor Complications included LBBB in one patient; two patients developed mild to moderate tricuspid regurgitation, two patients developed trivial aortic insufficiency. On follow up, the LVEDD improved from a mean of 4.4 cm (3.4 - 5.9) to a mean of 4.0 cm (3.2 - 5.5 cm) at three months follow up, p< 0.05.
We concluded that transcatheter occlusion of perimembranous
and muscular VSDs is safe, feasible, effective
with high success rate and low complications.
We are still following these patients for longer
time to look at their long term results.
The use and placement of self-expandable stents in children reported are very limited in the literature. The improved wall stent of the radial power and flexibility make this category of stents more amenable to pediatric use.
Methods: We are reporting our experience in our institution, Hamad Medical Corporation, Qatar, of three children in whom we used improved version of wall stents. The sites of implantations are inferior vena cava, right branch of pulmonary artery and right ventricle to PA conduit. A total of three stents were used in these three patients. The age of these children was 10 to 15 years; two males and one female. The stenoses at these sites were relieved with reduction of gradient across them to less than 70%. We didn’t observe any complication of vessel rupture, bleeding, migration of the stent, subsequent thrombosis or recurrence of stenosis.
Conclusion:
Self-expandable stents are safe to use in children
with very low complication rate. Larger cohorts
are needed to confirm this pilot study.
Huang first introduced radio frequency ablation of ectopic foci and accessory pathways in 1986. In the last 10 years this modality of therapy became the treatment of choice in several arrhythmias.
Methods: In our center (Hamad Medical Corp. Qatar) we treated a total of 22 patients diagnosed with supraventricular tachycardia and ventricular tachycardia. 10 patients were females and 12 were males. Age ranged from 4 to 56 years. 10 patients had AV node reentry tachycardia, 6 had Wolf Parkinson White, two had ectopic atrial tachycardia, 3 had atrio-ventricular tachycardia and one had ventricular tachycardia. Our success rate was 21 out of the 22 patients. No major complications of death, CVA or pericardial effusion were reported. No recurrence after successful ablation on follow up more than two months. In this abstract we present four patients who attended the emergency room with life threatening arrhythmia with symptoms of cardiogenic shock, requiring DC cardioversion. These four patients subsequently were taken to the Electrophysiology laboratory and treated by RF ablation of their arrhythmia substrate. All of them became arrhythmia free after the ablation treatment with no recurrence after a median follow up of four months.
Conclusion:
RF energy catheter ablation is a life-saving therapy
with high rate of success and very low mortality
and complications.
Methods: 55 patients with suspected or known coronary artery disease (CAD) referred for evaluation of myocardial ischemia by dobutamine stress echocardiography (DSE) were prospectively studied between Jan 2002 to Oct 2003 at our Echolaboratory Department, Royal Hospital, Muscat, Oman. All these patients underwent coronary angiography at our Catheterization laboratory under standard protocol. Patients were excluded if they had significant valvular disease, evidence of heart failure at the time of testing, atrial fibrillation, sustained arrythmias, and pregnancy. All medications were continued except beta-blockers during the study.
DSE was performed by a standard protocol in all patients using dobutamine infusion starting at 10 mcg/kg/min increasing every 3 min up to 40 mcg/kg/min. Atropine up to 2 mg was added if target heart rate was not achieved. 2D echocardiography was performed in 4 standard views using ATL HDI 5000 CV system using single phased array transducer (P4-2) in fundamental and harmonic imaging on a quadscreen format, displayed in a cine loop and digitally recorded on optical disk. Regional wall motion abnormalities (WMA) analysis was performed as described on standards of the American Society of Echocardiography. A 16-segment model dividing the left ventricle was used. The following scoring system was used for each segment: 1=normal, 2=hypokinesia, 3=akinesia and 4=dyskinesia. The test was considered positive for ischemia if there is new or worsening of WMA or wall motion score greater 1 in a segment compared to baseline was seen or a biphasic response of a rest dysynergy was noted.
Results: Coronary angiography demonstrated significant (> 50% stenosis) CAD in 35 patients and no significant disease in 20. One-vessel disease was present in 21 patients, two-vessel disease in seven, three-vessel disease in six and left main in one. Stress induced wall motion abnormalities developed in 31/35 patients (89%) who had significant CAD. There were four false-negative studies and they occurred in patients with single-vessel disease resulting in a sensitivity of 81% (17/21) for those with one-vessel disease and sensitivity of 100% (14/14) for those with multivessel and left main disease. Stress induced wall motion abnormalities were absent in 17/20 patients (85% specificity) who had no significant CAD. There were 3 false positive cases all of whom had < 50% stenosis in a single vessel. The location of stress-induced wall motion abnormalities correlated with the distribution of angiographically diseased vessel in 16/17 (94%) who had echocardiographic abnormalities and one vessel disease. The location of stress-induced abnormalities correlated with the distribution of at least one significantly diseased vessel in 13/14 patients (93%) who had multivessel or left main disease. Stress echocardiography correctly predicted the presence of multivessel disease in 10/14 (71%) based on multiregional wall motion abnormalities. Mild side-effects were seen in 2% of patients with no serious complications.
Conclusion:
Dobutamine stress echocardiography is a safe
and accurate noninvasive method of detecting or
ruling out coronary artery disease.
Pulmonary embolism (PE) is a major international
health problem and clinicians can miss it easily
if they do not have good clinical suspicion as
shown by the post-mortem studies. Among
the 19 cases of pulmonary embolism seen in Dubai
hospital, between 2000-2003 there were 10 (53%)
males and 9 (47%) females, ages between 26-74
years. The commonest complaint was shortness
of breath, which was found in 9(47%) patients,
chest pain in 7(37%) patients and 2 (10%) patients
presented with syncope. All the patients
had normal blood pressure (> 90/60) and 9 (47%)
patients had a heart rate above 100/minutes.
All patients had a positive V/Q scan positive,
suggestive of PE, apart from 1, which was not
done. 7 (37%) patients had a PAP of >35mmHg
assessed by echocardiography, and 5 (26%) of them
had evidence of dilated RV. Echo was not
done in 3(16%) patients. 5 (26%) patients
had ECG changes of tall R in V1 and 1(5%) had
S1Q3T3 pattern. 16(84%) patients were anticoagulated
using heparin and Warfarin, and 3 (16%) patients
were thrombolysed using r-TPA. An IVC filter was
inserted in 1(5%) patient. History of DVT
was found in 9(47%) patients, and 2(10%) patients
had LSCS before PE was diagnosed. 1 (5%)
patient had SLE, 1(5%) ischaemic dilated cardiomyopathy,
and 1(5%) sickle cell anaemia.
The character and mechanisms of simvastatin action on clinical course, function of the heart and coronary vascular system, activity of the systemic inflammation, lipid and glucose metabolism disturbances in patients with acute myocardial infarction in early and removed periods of recreation were explored. It was combined with the investigation of the interdependence between hypolipidemic, antiinflammatory and antioxidant activity of simvastatin and its influence on carbohydrate metabolism in rabbits with induced inflammation. Simvastatin in investigated patients had a moderate hypolipidemic action in association with significant lowering of the plasma atherogenic abilities which were tested by capture of modified lipoproteins with mouse macrophages. This effect of simvastatin was the reflection of its antiinflammatory, antioxidative action and glucose metabolism normalization. This action of simvastatin stipulated for the significant improvement of the myocardial contractile function and increasing of the physical tolerance during rehabilitation.
In the
experimental part of the investigation the direct
anti-inflammatory, antioxidant, and antiatherogenic
actions of simvastatin was established and was
found to be due to its ability to suppress the
activity of inflammatory blood cells (macrophages,
monocytes and neutrophils) and normalization of
glucose metabolism. This led to the lowering
of plasma lipoprotein atherogenity in association
with the suppression of macrophages ability to
absorb the modified lipoproteins.
Cytochrom P 450 2C9 isoenzyme (CYP2C9 ) metabolizes a wide range of drugs including S-Warfarin. Genetic variations in CYP2C9 gene may lead to significant differences in warfarin metabolism resulting in variable patient response to the drug. In addition to the wild type allele CYP2C9*1, CYP2C9 gene has two allelic variants viz CYP2C9*2 and CYP2C9*3, which may decrease enzymatic activity by 30% and 80% respectively. It has been reported that a strong association between CYP2C9 variant alleles and low dose warfarin requirement exists.
In this
study, we determined the frequencies of CYP2C9
allele variants in Omani patients receiving warfarin.
DNA was isolated and PCR-RELP method was used
to study CYP2C9 gene polymorphism. Preliminary
data after genotyping 37 out of 200 patients DNA
samples showed that 10.8% and 13.5% of the sample
were heterozygous for the CYP2C9*2 and CYP2C9*3
alleles, respectively. Besides 5.4% were
homozygous for the CYP2C9* allele. No homozygous
DNA samples were found for the CYP2C9*3 allele.
The allele frequency of CYP2C9*3 in Omani subjects
(0.068) was similar to that of Causcasian populations
(0.060 – 0.100) and higher than of East Asian
populations (0.011 – 0.026). The frequency
of CYP2C9*2 allele (0.108) was also similar to
that of Caucasian populations. These data
imply that about 30% of Omanis are slow metabolizers
of warfarin. The frequency of the two slow
CYP2C9 allele variants in Omani subjects was similar
to that of Caucasian populations.
Aim: To look at the surgical outcome and intermediate follow up after repair of complete AV Canal defect.
Material & Method: From June 1992 to December 2002, a total of 73 children (age range: 1 month to 84 months, median 10 months) underwent repair of complete AV canal defect at The Royal Hospital. The weight of these patients ranged from 2.5 kg to 15 kg (median 5.6 kg). 59 patients (80.9%) had Down’s syndrome. Surgical repair was by a two patch technique in 68 patients. Associated lesions included Fallot’s (6), DORV (1), Unroofed coronary sinus (4), Secundum ASD (8) and a large PDA (32).
Results: There were 11 (15.06%) early deaths. Seven of these patients were older than 6 months. There were three late deaths two months to three years after surgery. Of the 59 survivors 8 patients have been lost to follow up. 51 patients have been followed up from six months up to 120 months (median 55 months). 8 patients have undergone re-surgery for residual lesions. 31 patients are in class I without medications. The rest are in class I – II on medications.
Conclusion: Our results demonstrate that the intermediate outcome after repair of complete AV canal defect is quite satisfactory. Patients operated after six months of age are at a higher risk.
The incidence of seizure related non-fatal cardiac arrhythmias range from 1:525 to 1:2100 of episodes. Associated bradycardia and asystole, although rare, could be life threatening and occur mostly in older children. A close differential diagnosis is a primary cardiac arrhythmia that leads to cerebral hypoperfusion, as in patients with congenital long QT syndrome.
Five children who were primarily diagnosed to have seizures, but found subsequently to have an underlying cardiac arrhythmia are presented. Case 1 was a 6-month old infant girl with resistant seizure disorder. While in hospital, she developed generalized tonic clonic seizures, and during the episode of seizure, developed severe bradycardia and cardiac asystole. She required cardiac pacemaker implantation in addition to anticonvulsant therapy, but succumbed to the event subsequently. Case 2 was a 15-month-old infant boy, who developed febrile seizures and was hospitalized. On arrival in the hospital, he was noted to have ventricular tachycardia, and required therapy with amiodarone and flecainide in addition to anticonvulsants. This patient recovered subsequently. Case 3 was a 12-year-old girl who had repeated episodes of palpitations followed by generalized tonic clonic convulsions. The cardiac arrhythmia was identified as a reentry tachycardia, and treated. However, the episodes persisted and she responded to a course of carbamazepine. Case 4 was a 10-year old girl who was referred with history of unconsciousness followed by abnormal movements of acute onset. Examination revealed complete heart block with intermittent episodes of ventricular fibrillation. She required implantation of a permanent pacemaker, and has been asymptomatic subsequently. Case 5 was a 1-month old infant boy who had two episodes of loss of consciousness with generalized tonic clonic seizures associated with cyanosis. He had congenital long QT syndrome and was placed on beta-blocker therapy, with no recurrence of symptoms.
The differential diagnosis and pathophysiology of arrhythmia-related seizures are discussed, and the need for regular cardiac monitoring during episodes of seizures or seizure like events emphasized.
Objective: Radial access for coronary artery intervention promises fewer access site complications and improved patient comfort via immediate ambulation. However, this transradial coronary angioplasty technique appeared to be technically more demanding compared to the traditional femoral technique which has hindered its wider acceptance. The purpose of this study was to assess the applicability and learning curve of transradial intervention in the Saudi population for operators without prior experience in this approach.
Methods: After confirming a normal Allen’s test, right radial artery cannulation was performed and a 6F sheath was inserted. Standard 6F guiding catheters were used for the coronary intervention. The anti-thrombotic therapy was at the discretion of the operator.
Results: Transradial coronary intervention was successful in 214 vessels in 188 patients. It was unsuccessful in 4 (2%) due to access failure (1), or inability to engage the ostium. 187 patients were men (99%); mean age was 54 years, mean weight was 80 kg, and 50% were diabetic. Abciximab was used in 12%, 7% were primary intervention for acute myocardial infarction and 27 patients (14%) underwent multivessel intervention. The mean procedure time was 53 minutes and the mean fluoroscopy time was 15 minutes. The Extra-backup 3.0 or JL3.5 guide catheter was used for 88% of the 143 LAD or circumflex interventions and the JR4 guide catheter was used for 80% of the 71 RCA interventions. There were no bleeding or ischemic complications in the 188 patients.
Conclusions: Transradial access for coronary intervention is successful in 98% of the procedures and is very safe even with relatively inexperienced operators.
Background: Coronary artery disease (CAD) is the leading cause of death in Kuwait, yet data about patient characteristics and practice patterns is lacking.
Objectives: To establish a registry of all acute myocardial infarction (AMI) cases admitted to the general hospitals in Kuwait, so that the characteristics and management patterns of patients with AMI could be accurately determined.
Methods: For six consecutive months we prospectively included all AMI patients admitted to the coronary care units of the five participating hospitals.
Results: Of the 662 patients, 87% were men. The mean age was 55 years. History of diabetes, hypertension and current smoking was found in 41%, 35% and 49%, respectively. History of hypercholesterolemia or fasting cholesterol 5.2 mmol/l was found in 56% of the patients. Eighty percent suffered ST-segment elevation AMI. We identified 476 patients who were eligible for thrombolytic therapy, 12 of whom (3%) did not receive it. The median time from diagnostic electrocardiogram to thrombolytic therapy was 45 minutes. The rate of prescribing aspirin, beta-blockers, angiotensin converting enzyme inhibitors (ACEI) and statins at discharge among survivors was 98%, 86%, 51%, and 50%, respectively. The in-hospital mortality was 6.2%.
Conclusions: Our AMI population is characterized by young age and high rates of diabetes, smoking, and hypercholesterolemia. The majority had ST-segment elevation AMI. Thrombolytic therapy is appropriately utilized, but measures need to be introduced to decrease the time to treatment. The rate of use of aspirin and beta-blockers is appropriate, while the use of ACEI and statins needs improvement.
Objectives: The aim of the study was: 1) to examine in-hospital mortality after acute myocardial infarction ( AMI ) in diabetic and non-diabetic patients and 2) to evaluate if this association remains the same across ethnicity and gender.
Methods and Results: We used a 1:1 individual matched retrospective case control study. All patients admitted to Mubarak Al-Kabeer Hospital in Kuwait with a diagnosis of AMI during August 1997 to July 2000 made up the study population. All 137 patients who died in hospital during this period made up the cases. Control subject to match each case was randomly chosen from survivors, after hospitalization with AMI. Cases and controls were matched for age, sex and ethnicity.
History of diabetes mellitus (DM) was found to be significantly associated with in-hospital mortality after AMI (odds ratio: 2.35, 95% CL: 1.39 – 3.97). None of the other cardiovascular related histories were associated with mortality. This association was prominent among Kuwaiti patients (odds ratio: 3.0, 95% Cl: 1.5-5.9), and not significant among non- Kuwaiti population 9 odds ratio: 1.5, 95% Cl: 0.7 – 3.6). The association was not found to be different between males and females.
Conclusions: Risk of in-hospital mortality after AMI is more than doubled among diabetic patients. This association was found to be significantly higher among Kuwaiti Arabs.
Introduction: The Holy month of Ramadan and the Eid holiday that follows marking the end of fasting are considered a special time for millions of Muslims around the world. The month of Ramadan is associated with dramatic changes in eating habits, sleep and work pattern, and behavior. Hematological and biochemical changes in the body have been reported during Ramadan. However, there are no substantial studies regarding the influence of Ramadan and the Eid days that follow on patients’ clinical conditions, especially as relates to the incidence of heart disease.
Aim: Our aim was to study: (1) the influence that Ramadan fasting might have on the incidence of acute myocardial infarction (AMI) and (2) the influence that Eid days might have on the incidence of AMI.
Methods: The source of this analysis is Mubarak Al-Kabeer Hospital Coronary Care Unit Registry. We identified the months of Ramadan in the last 5 years and systematically identified the incidence of AMI cases that were admitted during, before and after Ramdan. The incidence of AMI in the last 5 days immediately after Ramadan (Eid Days) was also studied.
Results: The table shows the number of AMI admissions during Ramadan, before and after in 5 consecutive years.
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Conclusion: There were no significant differences in AMI admissions during Ramadan months compared to one month prior to it.
Background: Khat chewing is a common habit in Yemen and East African countries. Millions of people chew khat leaves every day. The main effect of khat is increased energy, alertness and relaxed feeling. Cathinone is the main active substance in fresh khat leaves with sympathomimetic effect.
Aims: To determine if khat chewing is a potential risk factor for development of acute myocardial infarction (AMI).
Design: A hospital – based matched case control study
Method: 100 patients admitted with acute myocardial infarction to the ICU of Al Thawra Teaching Hospital, Sana’a Yemen enrolled between 1997 and 1999. 100 control subjects matched to cases for sex and age were recruited from the out patients clinics of the same hospital.
Results: Khat chewing was significantly higher among the AMI cases group than control group (OR – 5.0, 95% CI 1.9 – 13.1). A dose-response relationship was observed, the heavy khat chewers having 39 times increased risk of AMI.
Conclusion: This study indicates that khat chewing is associated with acute myocardial infarction and is an independent dose-related risk factor for the development of the myocardial infarction.
A 30-year-old male presented with advanced renal failure (serum creatinine 612 umol/l) with uncontrolled hypertension which was noted two years earlier. Detailed workup was pursued. Considering young age of the patient and a diagnosis of glucocorticoid responsive aldosteronism was established. Appropriate therapy could be achieve better Hypertensive control resulting in improvement of renal function (< 200 umol/l) which has retained stable over last three & half years. The case is considered worth reporting since author feels that this case exemplifies some common pitfalls in primary management of hypertension & great benefit incurred from good control of hypertension. In general & in specialist clinics too, hypertensive patients are not investigated adequately for secondary causes resulting in poor control of hypertension & early occurrences of end-organ damage; an associated grossly deranged renal function is considered more often a cause rather than the effect of hypertension, leading to error in management. Community physicians required to be stressed about the need & benefit of hypertension control in terms of cost-saving & improvement of quality of life by thoughtful management. The presentation discusses common pitfalls in primary management of hypertension & a simplified approach for work-up for suspected secondary useful for general practitioners & physician.
Introduction: Approximately 14% of patients with chest pain are under the age of 40 years. The prevalence of coronary artery disease (CAD) in Pakistan is probably as high as in developed countries.
Study Objectives: 1) To assess the frequency of acute coronary syndrome (ACS) in less than 40 years of age patients; 2) To determine predictive factors for better identification of individuals with ACS.
Subjects: Hundred young patients of either sex with chest pain and in whom an ECG was done were included. Patients with pre-established cardiac diseases were excluded from the study. The study was conducted from June 2002 to February 2003.
Methods: A data collection form was completed that included data regarding demographics, cardiac risk factors, cardiac history, physical examination findings, final Emergency Department (ED) diagnosis and disposition.
Results: n = 77 were admitted in the hospital and n = 23 were discharged through ED. Final diagnosis of patients consisted of n = 16 with muscukoskeletal chest pain, n = 20 with MI, n = 7 with psychogenic, n = 4 with angina,
n = 47 with atypical chest pain, n = 2 with gastritis and n = 4 with others (left sided empyema, pneumonia, tuberculous pericarditis and takayasu
arteritis).
Conclusion: It was found that young patients presenting to ED with chest pain had a greater likelihood of suffering from ACS if they are male and between 30 to 40 years of age. Most patients who suffered from MI had some evidence of abnormality on clinical examination like an elevated JVP, rales and S4. People of any age group presenting to ED with chest pain should not be disregarded and should be thoroughly evaluated with special attention in the presence of cardiac risk factors and physical findings.
Introduction: Despite improvement in surgical techniques, treatment of heart valve disease in children remains controversial. Somatic growth and adequate anticoagulation levels are of concern when children undergo valve replacement. This study was conducted to evaluate the performance of valve replacement in this age group.
Methods: A retrospective study of 34 children below thirteen tears who underwent valve replacement was conducted. 38 valves were implanted in 34 patients; 37 mechanical and one bioprosthetic valve. 26 underwent MVR, 2 AVR, 4 DVR, 1 had tricuspid valve replacement and 1 had pulmonary valve replacement. Preoperatively, 13 (38.2%) were in NYHA Class IV, while 21 ( 61.7%) were in NYHA Class III.
Results: There were 2 (5.8%) hospital deaths, 27 (79.4% ) patients were in NYHA Class I and free from all medication except warfarin. 3 (8.6%) patients have undergone 4 successful pregnancies.
Conclusion: In view of problems of sizing, anticoagulation and need for re-operation at an early age, there is reluctance for valve replacement in children. This study shows that despite this problem, replacement can be undertaken with good results, if repair is not technically feasible.
Aim: To assess whether female sex is a factor independently related to in-hospital mortality in acute myocardial infarction in a geographically defined population in the developing world.
Methods: A total of 20,856 patients were treated with various cardiovascular disorders during the ten years (1991-2001), 8446(40.5%) of them were Qataris. Of 1598 consecutive patients (1147 males and 451 females) with acute myocardial infarction were studied. Clinical characteristics, medical therapy and in-hospital outcome were analyzed.Multivariate analysis was done to evaluate whether female gender was an independent predictor for poor outcome.
Results: Females were older (p<0.0001) and had a higher incidence of hypertension (p<0.0001), hypercholesterolmia (p=0.026), and diabetes mellitus (p<0.0001). Males were more frequently to be smokers (p<0.0001). Female patients were more likely to receive thrombolytic therapy and aspirin. The in-hospital mortality was significantly higher in women when compared top men (18.4% vs. 13.9%; P=0.025) and they were more likely to develop stroke (2.9% vs. 1.0%) and heart block (6.4% vs. 3.3%). However, after adjustment for all baseline variables, female gender was not an independent predictor of increased risk of in-hospital mortality (p=0.75).
Conclusion: Women with AMI have higher in-hospital mortality because of worse baseline clinical characteristics and less likely to receive appropriate therapy. When compared to men Regional and global measures to fight coronary artery disease and its risk factors in women are urgently needed.
Many studies suggest that consumption of hydrogenated fat may increase the risk of coronary heart disease, while monosaturated fats may be associated with a lower coronary risk profile. Oxidative damages including those associated with lipid peroxidation are generally believed to be a significant factor in much pathological process. In the pathogenesis of atheroclerosis, there is evidence, that increasing the lipoprotein peroxidation may be involved. In Iran, about 22% of total calories is derived from fat, especially hydrogenated fat about 5-10 %. Olive oil is the usual diet in Mediterranean countries and is rich in monodaturated fatty acids especially oleic acids, and has an optimal linoleic / linoleic ratio and is rich in antooxidants.
Aim: To compare the effects of hydrogenated fat and olive oil in lipid peroxidation and probable modulating effect of substituting olive oil in diet.
Methods: Adult male rabbits were allocated in 4 groups, according to their dietary type. Collection of blood were made before the beginning of dietary treatment, and the end of period (12 weeks).
Results: Comparison of four groups after experimental period showed that mean of MDA was the highest in the hydrogenated fat group (P = 0.01) and anhtioxidant capacity was the highest in the hydrogenated fat + olive oil groups (N.S.) The comparison of olive oil and hydrogenated fat group showed that hydrogenated fat group had higher mean of MDA and antioxidanr capacity than the other group, but was significant only about MDA. The comparison of hydrogenated fat and combined group (hydrogenated fat+olive oil), showed that means of MDA were higher in hydrogenated fat group than the other group.
Conclusion: In conclusion, undesirable effects of hydrogenated fat on lipid peroxidation could be modulated by substituting olive oil in the diet.
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